Re: Sharon - Shoulder Questions -Mike

[Guest guest]

Mike Wrote:

> To begin with, I need to know EXACTLY which bone you mean when you

> say your " shoulder " dislocates subclavicularly.

I mean the " True Shoulder " (i.e the humerous, the ball of my ball and

socket etc) sits under my clavicle (OUCH). This is why my Orthopaedic

surgeon doesn't know what to do about it. It is a very painful

experience (and I have TOS and have had it for ages and this is

playing HELL with it). I can feel the ball part of the ball and

socket sticking out the front of my " chest " (for want of a better

word) next to wear it should sit and " partly " below the end of the

clavicle and partly under it. My Osteopath has had to relocate this

every week and I also end up in the ER sometimes, othertimes if the

pain and limitatins aren't too bad and my osteo appointment is not

too far away, I tend to leave it as I find the ER is SO brutal when

they relocate it, that they make things worse (especially the pain)

by trying to relocate it.

We are not sure why my shuolder has started doing this but my

Osteopath has been saying something about the fact that due to the

shoulder problems I have had since 1995 and the RSD in this arm that

I do have some muscles that have tightened (pectoralis was one) and

seem to be helping drag my shoulder in this odd direction without

trauma. I am supposed to wait for it to go out and then go off and

have x-rays and a CT scan for my Orthopaedic surgeon but this last

time I was in so much pain and the TOS symptoms were so bad that I

just wanted it back and my osteo did relocate it but this time it

took quite a while for it to relocate as he had to loosen of a lot of

stuff to allow it back.

I think my shoulder blade may be involved a little simply due to what

the shoulder/humerus does (I do get some pain in the back area but

then with the shoulder being where it is NO wonder).

I know that Anterior Inferior (forward and down) is the common way

and that is why I was asking if I am the only one whose body is doing

THIS. I knew I was strange but Hey I didn't think I was THIS WEIRD

.

Thanx anyway Mike.

The information you sent was interesting and I am trying to work on

loosening the pectoralis and things (I tend to carry this shoulder

forward all of the time and when out it tends to sit even further

forward).

Sharon

> This is a second attempt resend.

>

>

> To begin with, I need to know EXACTLY which bone you mean when you

> say your " shoulder " dislocates subclavicularly. The " true "

shoulder

> joint is the glenohumoral joint - the ball and socket joint holding

> the head of the humorus (the upper arm bone)in the glenoid fossa by

> the rotator cuff muscles (supraspinatus, infraspinatus, teres

minor,

> and subscapularis). The " shoulder " bone is the scapula. The top

is

> called the spine of the scapula. Out at the shoulder, it takes a

> little dog-leg toward the front. That flat " dog-leg " is called the

> acromion process. The clavicle connects with the acromion process

> and forms a joint called the acromioclavicular joint, or a-c joint

> for short. In addition, there is another protrusion from the spine

> of the scapula called the coracoid process. It also points forward

> like the acromion process but comes in under the clavicle and is a

> couple of fingers medial to the acromion. It is an important

muscle

> and ligament attachment point.

>

> So, in terms of bones, we have three: scapula, clavicle, and

> humorous. When most people say they have a dislocated shoulder,

> they are referring to the humorus coming out of the glenoid fossa.

> If the bones are still making contact, it is a subluxed shoulder.

> If it is completely out, it is dislocated. The other case is a

> separation of the clavicle at the acromion process. Again, if the

> two bones are still in contact, but out of proper position, it is

> technically subluxed. If they are not making contact at all, it is

> a dislocation, although the technical term normally used is an AC

> separation.

>

> Given the above technicalities and comparing them to your

> description, it SOUNDS like your scapula is rotating forward such

> that the acromion process is sliding under the end of the

clavicle.

> And it can't just rotate forward by itself - it has to be pulled

out

> of position by a contracted muscle.

>

> So let's talk a bit about muscles and muscle actions. The true

> shoulder, being a ball and socket joint, allows eight possible

> movements OF THE UPPER ARM. These include flexion, extension,

> horizontal abduction, horizontal adduction, abduction, adduction,

> medial rotation and lateral rotation. The specific muscles

involved

> for each action are listed below. For the most part, these actions

> occur because one end of the muscle is attached at some point on

the

> humorus while the other is attached at some point on the scapula

(in

> back) or on ribs (in front).

>

> Flexion:

> Deltoid - anterior fibers

> Pectoralis major - upper fibers

> Biceps brachii

> Coracobrachialis

>

> Extension:

> Deltoid - posterior fibers

> Latissimus dorsi

> Teres major

> Infraspinatus

> Teres minor

> Pectoralis major - lower fibers

>

> Horizontal Abduction:

> Deltoid (posterior fibers

> Infraspinatus

> Teres minor

>

> Horizontal Adduction:

> Deltoid - anterior fibers

> Pectoralis major - upper fibers

>

> Abduction:

> Deltoid - all fibers

> Supraspinatus

>

> Adduction:

> Latissimus dorsi

> Teres major

> Infraspinatus

> Teres minor

> Pectoralis major

> Triceps brachii - long head

> Coracobrachialis

>

> Medial Rotation:

> Deltoid - anterior fibers

> Latissimus dorsi

> Teres major

> Subscapularis

> Pectoralis major

>

> Lateral Rotation:

> Deltoid - posterior fibers

> Infraspinatus

> Teres minor

>

> The scapula is called the scapulothoracic joint although it is not

> in fact a true joint. There are six possible motions that the

> scapula can perform: elevation, depression, abduction, adduction,

> upward rotation, and downward rotation. The involved muscles are:

>

> Elevation:

> Trapezius - upper fibers

> Rhomboid major

> Rhomboid minor

> Levator scapula

>

> Depression:

> Trapezius - lower fibers

> Serratus anterior

> Pectoralis minor

>

> Abduction:

> Serratus anterior

> Pectoralis minor

>

> Adduction:

> Trapezius - middle fibers

> Rhomboid major

> Rhomboid minor

>

> Upward Rotation:

> Trapezius - upper and lower fibers

>

> Downward Rotation:

> Rhomboid major

> Rhomboid minor

> Levator scapula

>

> All I listed up above are the muscle actions and specific muscles

> involved in performing those actions. I did not list origin and

> insertion points for each muscle because of the amount of space

> required to do so. If you want that information, let me know. I

> have a very detailed set of notes I worked up when I was in school

> that I can send you off list my email attachment. The main point

of

> all this is that bones don't do anything by themselves – whatever

> they do is done by muscle contraction. And if you are having a

> problem with a bone doing something it shouldn't, you need to

> identify which muscle is involved with making it do whatever it is

> that it is doing.

>

> If you are talking a true shoulder dislocation, the NORMAL action

or

> direction that the humorus will do/take is to drop out and down.

In

> other words, it is going to move away from the scapula/clavicle.

In

> general, this will be because of a weakness in one or more of the

> muscles (usually the rotator cuff muscles) that help hold it

> securely in the socket. The only ways that it can move out and up

> would be either from trauma (an impact forced it into that

position)

> or there is a severely contracted muscle that pulls the humorus up

> and out. You aren't talking trauma here. You are talking – oh,

I'm

> just minding my business, going about my daily routine, and it

> decides all by itself to ruin my day.

>

> That's part of why I don't think it is the humorus. The other

> reason is your description of going under the clavicle. That

sounds

> like an AC separation or sublux. Again, we are not talking

specific

> trauma to cause it – it just does it to you. That is suggestive of

> muscle action. Now, this could either be a case of one muscle

> overpowering its antagonist by being in chronic contracture OR it

> could be a case of the antagonist being weak and the other muscle

is

> doing its thing from just normal strength. And in addition to the

> specific muscles at the ac joint, there are also several ligaments

> that might be acting up.

>

> Specifically, there are four ligaments that connect the clavicle to

> the scapula: The acromioclavicular ligament joins the acromion

> process and the clavicle. The coracoacromial ligament actually

runs

> between the acromion process and the coracoid process of the

> scapula. The trapezoid and conoid ligaments run from the bottom of

> the clavicle to the upper medial edge of the coracoid process. If

> these ligaments become weak or stretched, the ac joint will also

> become weak and unstable. If you then add some muscle imbalances

to

> the equation, you end up with a shoulder separation.

>

> And since the area beneath the clavicle on the front of the

shoulder

> is called the brachial plexus (because of all the brachial

arteries

> and nerves that pass through there), it is not surprising that you

> would be having arm and/or hand pain. You would be getting a nice

> touch of Thoracic Outlet Syndrome.

>

> Given all of the above, my guess is that you are having a problem

> with weak ligaments, as well as either chronically contracted or

> chronically weak antagonist muscles that are pulling the scapula

> forward and under the clavicle. You could also be having a case

of

> the clavicle itself getting dislocated which then allows the

scapula

> to slide under.

>

> Digest some of this and get back to me. Depending on what you

think

> it might be, there definitely are some energy techniques that might

> help. I have put more than one clavicle back in place with nothing

> but energy doing bone two-pointing.

[Guest guest]

No wonder your shoulder hurts like hell!

Now that I know exactly which bone you are talking about, we can

look in more detail at the involved muscles. Again, the only ways

the head of the humerus can in essence go up and forward is either

through trauma - something rams it in that direction by force - or

it gets pulled in that direction by a contracted muscle. So, which

muscle(s) attach to the head of the humerus in such a way that they

could move it in that direction?

Before I get into that in detail, we need to remember that it could

be one of two things. It could either be a strong contraction of

the main muscle overpowering normal antagonistic muscle strength OR

it could be a case that the antagonistic muscle is so weak that a

minimal contraction of the main muscle is enough. In the first

case, you work primarily toward relaxation of the contracted

muscle. In the second case, you work primarily toward strengthening

the antagonist. In reality, you probably need to work on both.

And you need to remember that there are 18 different muscles that

act on the shoulder joint. I copied the Shoulder and Arm section of

my school notes down below. Spacing is a bit choppy but I think you

will be able to figure it out.

What you need to do is visualize what your arm (ball/head of the

humerus) is actually physically doing - what action is happening.

Then look at the muscle attachments notes and see which muscles

could be causing that specific action.

You said you can feel the head of the humerus under the clavicle,

beneath the acromion process, and protruding slightly to the front

of your chest. The question then becomes does it feel like it is

moving straight up, straight forward, moving in a medial rotation, a

combination? Can you get any feel from the notes as to which

muscles might be the culprit?

For now, just take a look at it and then get back to me and we can

kick it around some more.

As for your scapula being involved, it is more likely that you are

getting muscle pain from compensation instead of actual direct

involvement. For now, focus on the shoulder muscles and we can look

at the scapula connections later.

Let me know if you are not sure of the meanings of the actions, such

as medial rotation, abduction, etc.

SHOULDER AND ARM

BONES AND BONY LANDMARKS MUSCLES

ACROMIOCLAVICULAR JOINT (AC) BICEPS BRACHII

CLAVICLE CORACOBRACHIALIS

CORACOID PROCESS DELTOID

DELTOID TUBEROSITY LATISSIMUS DORSI

GREATER TUBERCLE LEVATOR SCAPULA

INFERIOR ANGLE PECTORALIS MAJOR

INFRAGLENOID TUBERCLE PECTORALIS MINOR

LATERAL BORDER RHOMBOID MAJOR

LESSER TUBERCLE RHOMBOID MINOR

MEDIAL BORDER ROTATOR CUFF MUSCLES

SPINE OF THE SCAPULA SUPRASPINATUS

STERNOCLAVICULAR JOINT (SC) INFRASPINATUS

SUBSCAPULAR FOSSA SUBSCAPULARIS

SUPERIOR ANGLE TERES MINOR

SUPRASPINOUS FOSSA SERRATUS ANTERIOR

SUBCLAVIUS

TERES MAJOR

TRAPEZIUS

TRICEPS BRACHII

DELTOID

ORIGIN LATERAL ONE THIRD OF CLAVICLE, ACROMION AND SPINE OF SCAPULA

INSERTION DELTOID TUBEROSITY

ACTIONS

ALL FIBERS ABDUCT THE SHOULDER JOINT

POSTERIOR EXTEND AND LATERALLY ROTATE THE SHOULDER JOINT

ANTERIOR FLEX AND MEDIALLY ROTATE THE SHOULDER JOINT

TRAPEZIUS

ORIGIN EXTERNAL OCCIPITAL PROTUBERANCE, MEDIAL PORTION OF SUPERIOR

NUCHAL LILNE OF OCCIPUT, LIGAMENTUM NUCHAE AND SPINOUS

PROCESSES OF C-7 THROUGH T-12

INSERTION LATERAL PORTION OF CLAVICLE, ACROMION AND SPINE OF

SCAPULA

ACTIONS

UPPER

BILATERAL EXTEND THE HEAD AND NECK

UNILATERAL EXTEND, LATERALLY FLEX, ROTATE HEAD AND NECK TO

OPPOSITE SIDE,

ELEVATE, UPWARDLY ROTATE THE SCAPULA

MIDDLE ADDUCT, STABILIZE THE SCAPULA

LOWER DEPRESS, UPWARDLY ROTATE THE SCAPULA

LATISSIMUS DORSI

ORIGIN SPINOUS PROCESSES OF LAST SIX THORACIC VERTEBRAE, LAST

THREE OR FOUR RIBS, THORACOLUMBAR APONEUROSIS, AND

POSTERIOR ILIAC CREST

INSERTION CREST OF THE LESSER TUBERCLE OF THE HUMEROUS

ACTIONS EXTEND, ADDUCT, MEDIALLY ROTATE THE SHOULDER JOINT

TERES MAJOR

ORIGIN DORSAL SURFACES OF INFERIOR ANGLE AND LOWER HALF OF

LATERAL BORDER OF SCAPULA

INSERTION CREST OF THE LESSER TUBERCLE OF THE HUMEROUS

ACTIONS EXTEND, ADDUCT, MEDIALLY ROTATE THE HUMEROUS

SUPRASPINATUS

ORIGIN SUPRASPINOUS FOSSA OF SCAPULA

INSERTION GREATER TUBERCLE OF HUMEROUS

ACTIONS ADDUCT HUMEROUS, STABILIZE HEAD OF HUMEROUS IN GLENOID CAVITY

INFRASPINATUS

ORIGIN INFRASPINOUS FOSSA OF SCAPULA

INSERTION GREATER TUBERCLE OF HUMEROUS

ACTIONS LATERALLY ROTATE, ADDUCT, EXTEND THE SHOULDER JOINT,

STABILIZE HEAD OF HUMEROUS IN GLENOID CAVITY

SUBSCAPULARIS

ORIGIN SUBSCAPULAR FOSSA OF THE SCAPULA

INSERTION LESSER TUBERCLE OF THE HUMEROUS

ACTIONS MEDIALLY ROTATE THE SHOULDER JOINT,

STABILIZE HEAD OF HUMEROUS IN GLENOID CAVITY

TERES MINOR

ORIGIN SUPERIOR HALF OF LATERAL BORDER OF SCAPULA

INSERTION GREATER TUBERCLE OF HUMEROUS

ACTIONS LATERALLY ROTATE, ADDUCT, EXTEND SHOULDER JOINT,

STABILIZE HEAD OF HUMEROUS IN GLENOID CAVITY

RHOMBOID MAJOR

ORIGIN SPINOUS PROCESSES OF T-2 TO T-5

INSERTION MEDIAL BORDER OF THE SCAPULA BETWEEN SPINE AND

INFERIOR ANGLE

ACTIONS ADDUCT, ELEVATE, DOWNWARDLY ROTATE THE SCAPULA

RHOMBOID MINOR

ORIGIN SPINOUS PROCESSES OF C-7 AND T-1

INSERTION MEDIAL BORDER OF THE SCAPULA BETWEEN SPINE AND

INFERIOR ANGLE

ACTIONS ADDUCT, ELEVATE, DOWNWARDLY ROTATE THE SCAPULA

LEVATOR SCAPULA

ORIGIN TRANSVERSE PROCESSES OF 1ST THRU 4TH CERVICAL VERTEBRAE

INSERTION MEDIAL BORDER AND SUPERIOR ANGLE OF SCAPULA

ACTIONS

UNILATERAL ELEVATE, DOWNWARDLY ROTATE THE SCAPULA, LATERALLY

FLEX HEAD AND NECK

BILATERAL EXTEND HEAD AND NECK

SERRATUS ANTERIOR

ORIGIN SURFACES OF UPPER 8 OR 9 RIBS

INSERTION ANTERIOR SURFACE OF MEDIAL BORDER OF SCAPULA

ACTIONS

WITH ORIGIN FIXED: ABDUCT THE SCAPULA, HOLD MEDIAL BORDER OF

SCAPULA AGAINST RIB CAGE

SCAPULA STABILIZED: MAY ACT IN FORCED INSPIRATION

PECTORALIS MAJOR

ORIGIN MEDIAL HALF OF CLAVICLE, STERNUM, CARTILAGE OF RIBS ONE THRU

SIX

INSERTION CREST OF GREATER TUBERCLE OF HUMEROUS

ACTIONS

AS A WHOLE ADDUCT, MEDIALLY ROTATE THE SHOULDER JOINT, MAY

ASSIST IN ELEVATING THE

THORAX IN FORCED INSPIRATION

UPPER FIBERS FLEX, MEDIALLY ROTATE, HORIZONTALLY ADDUCT THE

SHOULDER JOINT

LOWER FIBERS EXTEND, ADDUCT THE SHOULDER JOINT

PECTORALIS MINOR

ORIGIN THIRD, FOURTH AND FIFTH RIBS

INSERTION CORACOID PROCESS OF SCAPULA

ACTIONS DEPRESS, ABDUCT, TILT THE SCAPULA ANTERIORLY, ASSIST IN

FORCED INSPIRATION

SUBCLAVIUS

ORIGIN FIRST RIB AND CARTILAGE

INSERTION INFERIOR, LATERAL ASPECT OF THE CLAVICLE

ACTIONS DRAWS CLAVICLE DOWN AND FORWARD, ELEVATES 1ST RIB,

STABILIZES THE

STERNOCLAVICULAR JOINT

BICEPS BRACHII

ORIGIN

SHORT HEAD CORACOID PROCESS OF SCAPULA

LONG HEAD SUPRAGLENOID TUBERCLE OF SCAPULA

INSERTION TUBEROSITY OF THE RADIUS AND APONEUROSIS OF THE

BICEPS BRACHII

ACTIONS FLEX THE ELBOW, SUPINATE THE FOREARM, FLEX THE SHOULDER JOINT

TRICEPS BRACHII

ORIGIN

LONG HEAD INFRAGLENOID TUBERCLE OF SCAPULA

LATERAL HEAD POSTERIOR SURFACE OF PROXIMAL HALF OF HUMEROUS

MEDIAL HEAD POSTERIOR SURFACE OF DISTAL HALF OF HUMEROUS

INSERTION OLECRANON PROCESS OF ULNA

ACTIONS

ALL HEADS EXTEND THE ELBOW

LONG HEAD EXTEND, ADDUCT THE SHOULDER JOINT

CORACOBRACHIALIS

ORIGIN CORACOID PROCESS OF SCAPULA

INSERTION MEDIAL SURFACE OF MIDDLE SHAFT OF HUMEROUS

ACTIONS FLEX, ADDUCT THE SHOULD JOINT